Nokea
The health care provider's progress note for a patient states that the complete blood count (CBC) shows a 'shift to the left.' Which assessment finding will the nurse expect?
- A. Cool extremities
- B. Pallor and weakness
- C. Elevated temperature
- D. Low oxygen saturation
Correct Answer: C
Rationale: The correct answer is C: Elevated temperature. When a CBC shows a 'shift to the left,' it indicates elevated levels of immature polymorphonuclear neutrophils (bands), which is a sign of infection. In response to the infection, the body increases its temperature as part of the immune response. Choices A, B, and D are incorrect because cool extremities, pallor and weakness, and low oxygen saturation are not typically associated with a 'shift to the left' in a CBC; they are more indicative of other conditions or issues.
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Which patient requires the most rapid assessment and care by the emergency department nurse?
- A. The patient with hemochromatosis who reports abdominal pain
- B. The patient with neutropenia who has a temperature of 101.8°F
- C. The patient with thrombocytopenia who has oozing gums after a tooth extraction
- D. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours
Correct Answer: B
Rationale: The correct answer is B because a neutropenic patient with a fever is at high risk for developing sepsis. Sepsis can progress rapidly and lead to life-threatening complications. Immediate assessment, obtaining cultures, and initiating antibiotic therapy are essential in this situation. Choices A, C, and D do not present with the same level of urgency as a neutropenic patient with a fever. Abdominal pain in a hemochromatosis patient, oozing gums after a tooth extraction in a thrombocytopenic patient, and nausea and diarrhea in a patient with sickle cell anemia, while concerning, do not indicate the same immediate risk of sepsis as a neutropenic patient with a fever.
The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the
- A. Schilling test
- B. bilirubin level
- C. gastric analysis
- D. stool occult blood
Correct Answer: B
Rationale: The correct answer is B: bilirubin level. Jaundice, characterized by scleral jaundice, is caused by the elevation of bilirubin levels associated with red blood cell hemolysis. Checking the bilirubin level in the laboratory results will help assess the severity of jaundice in the patient. Choices A, C, and D are incorrect because the Schilling test is used to assess vitamin B12 absorption, gastric analysis is used to evaluate gastric function, and stool occult blood is used to detect hidden blood in the stool, which are not directly related to evaluating jaundice in a patient with hemolytic anemia.
A patient who has immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the healthcare provider before obtaining and administering platelets?
- A. Platelet count is 42,000/µL
- B. Petechiae are present on the chest
- C. Blood pressure (BP) is 94/56 mm Hg
- D. Blood is oozing from the venipuncture site
Correct Answer: A
Rationale: The correct answer is A. Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/µL unless the patient is actively bleeding. In this scenario, the platelet count of 42,000/µL is not significantly low to warrant a platelet transfusion without active bleeding. Consulting with the healthcare provider is essential before giving the transfusion to ensure the appropriateness of the treatment. Choices B, C, and D are not directly related to the need for consulting before a platelet transfusion. Petechiae, low blood pressure, and oozing from the venipuncture site are common findings in patients with ITP and may not necessarily contraindicate a platelet transfusion at this platelet count.
A patient is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching?
- A. Check frequently for swollen lymph nodes.
- B. Watch for excessive bleeding or bruising.
- C. Take iron supplements to prevent anemia.
- D. Wash hands and avoid individuals who are ill.
Correct Answer: D
Rationale: The correct answer is D. After a splenectomy, the patient is at an increased risk of infection, particularly from gram-positive bacteria. Washing hands and avoiding contact with individuals who are ill are crucial to reduce this risk. Choice A is incorrect because checking for swollen lymph nodes is not a priority after a splenectomy. Choice B is incorrect as while bleeding is a concern, it is more immediate post-operatively. Choice C is incorrect as iron supplements do not specifically relate to the risk of infection post-splenectomy.
A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect?
- A. Hematocrit of 46%
- B. Hemoglobin of 13.8 g/dL
- C. Elevated reticulocyte count
- D. Decreased white blood cell (WBC) count
Correct Answer: C
Rationale: The correct answer is C: Elevated reticulocyte count. Hemorrhage leads to the release of reticulocytes (immature red blood cells) from the bone marrow into circulation as a compensatory mechanism to replenish lost red blood cells. This response helps in restoring the oxygen-carrying capacity of the blood. Choices A and B, hematocrit of 46% and hemoglobin of 13.8 g/dL, may not reflect the immediate response to hemorrhage within 14 hours. Choice D, decreased white blood cell (WBC) count, is not directly related to the body's response to hemorrhage.